Chapter 8: Peri-Implant Health and Diseases PDF

CHAPTER 8 Peri-Implant Health and Diseases Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com. Anatomy of the Dental Implant and Surrounding Peri-Implant Tissues  Dental implant  Nonbiologic device surgically inserted into jawbone to replace tooth or provid...

CHAPTER 8 Peri-Implant Health and Diseases Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com. Anatomy of the Dental Implant and Surrounding Peri-Implant Tissues  Dental implant  Nonbiologic device surgically inserted into jawbone to replace tooth or provide support for multiunit prosthesis  Dental hygienist Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Plays important role in patient education and professional maintenance of dental implant The Dental Implant System Replaces individual teeth or multiple teeth by supporting fixed bridge or removable Courtesy of Rodger A. Lawton, Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Courtesy of Rodger A. Lawton, DMD, DMD, FACP, denture FACP, Olympia, WA. Olympia, WA. Courtesy of Rodger A. Lawton, DMD, Courtesy of Rodger A. Lawton, DMD, FACP, Olympia, WA. FACP, Olympia, WA.  Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Figure 09.F02A: Extracted teeth replaced by a traditional removable partial denture.  Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Figure 09.F02B: Missing teeth replaced by three individual dental implants.  Anatomy of a Endosteal Dental Implant Implant body—the “root” of the implant that is surgically placed in the living alveolar bone Abutment—titanium post that attaches to the implant body – Protrudes partially or fully through the gingival tissue Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com – Supports the crown or denture – Biocompatible (not rejected) with the body Copyright © 2016 Wolters Kluwer All Rights Reserved 6 Components of an Implant System  Implant body (implant fixture)  Abutment Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Prosthetic crown or prosthesis © Wolters Kluwer Implant Body  Surgically placed into living, vital alveolar bone  Acts as “root” of implant  Usually made of titanium or titanium alloy Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Lightweight, biocompatible, noncorrosive, poor conductor  Softer than other dental restorative metals, easily scratched, and can cause inflammatory reaction Implant Body (cont.)  Ceramics such as zirconia being used as alternative to titanium  Better esthetic outcome, Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com especially in patients with thin gingival phenotype Courtesy of CeraRoot USA Inc. Implant Abutment  Metal post that connects prosthesis to implant body and secures prosthesis in place Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Protrudes into oral cavity  Made of titanium or zirconia (ceramic)  Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Figure 8-4: A. Edentulous alveolar ridge. B. Initial osteotomy site established. C.Drills of increasing diameters used to prepare the osteotomy site to the size of the planned implant. D. Drills of increasing diameters used to prepare the osteotomy site to the size of the planned implant. E. Implant body seated in the osteotomy. The top of the implant body may be placed slightly above, level with, or slightly below the crest of the bone. F. Implant body seated in bone with cover screw attached. At the end of placement surgery, the implant can be covered with gingiva or left exposed to the oral cavity, as shown here. A healing time of several weeks to months is allowed so that osseointegration can occur. Peri-Implant Tissues  Hard and soft tissues that surround implant Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com © Wolters Kluwer  Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Peri-Implant Tissues (cont.) Implant-to-Epithelial Tissue Interface  Epithelium adapts to abutment post or implant, creating cuff-like perimucosal seal (biological seal)  Functions as barrier between implant and oral cavity  Sulcus lined by sulcular epithelium and junctional Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com epithelium surrounds implant abutment or collar Implant-to-Connective Tissue Interface  Implant surface lacks cementum  On natural tooth:  Supragingival fibers brace gingival margin against tooth and strengthen attachment of junctional epithelium to tooth Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Periodontal ligament suspends, maintains tooth in socket  Periodontal ligament fibers serve as barrier to infection Implant-to-Connective Tissue Interface (cont.)  On implant:  Supragingival fiber bundles support healthy gingiva against abutment  No periodontal ligament fibers to provide protection Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Periodontal probe passes more easily through inflamed peri-implant soft tissues to apical connective tissue or close to peri-implant alveolar bone Implant-to-Bone Interface  Osseointegration  Direct contact of living bone with surface of implant body  Criteria for osseointegration:  Absence of clinical mobility of implant Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  No discomfort or pain when implant is in function  No increased bone loss or radiolucency on radiograph  Less than 0.2 mm of bone loss annually after first year  Determines implant success Peri-Implant Health  Characterized by absence of erythema, bleeding on probing, swelling, and suppuration  No visual differences between healthy peri-implant tissues and healthy periodontal tissues Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Probing depths may be deeper at healthy implant site Peri-Implant Health (cont.) Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com © Wolters Kluwer © Wolters Kluwer © Wolters Kluwer Peri-Implant Mucositis (Peri-Implant Gingivitis) Plaque biofilm-induced inflammation of soft tissues with no loss of supporting bone Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com localized in mucosal © Wolters Kluwer tissues surrounding dental implant © Wolters Kluwer © Wolters Kluwer Peri-Implant Mucositis (cont.)  Reversible if etiologic factors removed  Occurs in 80% of patients and 50% of implant sites  Diagnosis requires: Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Visual signs of soft-tissue inflammation  Presence of bleeding and/or suppuration upon probing  Increased probing depths  Absence of bone loss  Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Peri-Implant Mucositis (cont.) Peri-Implant Mucositis (cont.) Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Black arrow: healthy, knifed-edged tissue. Yellow arrow: tissue is rounded, thickened, and swollen. The radiograph shows no signs of pathology. Peri-Implantitis  Periodontitis affecting soft and hard tissues surrounding functioning osseointegrated dental implant  Characterized by plaque biofilm-induced inflammation and progressive loss of alveolar bone Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Onset may occur early during follow-up and may progress in nonlinear and accelerating pattern  See Figure 8-16 Peri-Implantitis (cont.) figure 8-17  Can diagnose by detection of radiographic bone loss around implant  Range of differences in Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com prevalence from 6.61% to 47% © Wolters Kluwer  Residual cement noted. Peri-Implantitis (cont.)  Criteria for diagnosis of peri-implantitis:  Visual signs of inflammation  Presence of bleeding and/or suppuration upon probing  Increased probing depths Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Progressive bone loss is seen by examining bone levels comparing two radiographs (baseline and at 12 months)  Without initial radiographs and probing (lack of baseline records) radiographic evidence of bone level ≥ 3 mm and/or probing depths ≥ 6 mm  See Figure 8-18 Hard- and Soft-Tissue Deficiencies Bone resorption occurs after tooth loss, leading to hard-tissue deficiencies Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com See Figures 8-19 through 8-22 Hard and Soft Tissue Deficiencies (cont.)  Contributing factors:  Loss of periodontal support caused by periodontitis  Endodontic infections  Thin buccal bone plates Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Extraction with additional trauma to tissues  Traumatic injury  Systemic diseases impairing normal bone remodeling  Pneumatization of maxillary sinus Etiology of Peri-Implant Diseases  Peri-implant mucositis  Primarily result of biofilm-induced infection  Considered precursor of peri-implantitis  Peri-implantitis Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Result of overwhelming bacterial infection  Progresses similarly as periodontitis  No single microorganism implicated as the causative agent Risk Factors for Peri-Implant Diseases  History of previous periodontal disease  Poor plaque biofilm control and lack of regular maintenance therapy Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Smoking  Residual cement  Biomechanical forces and overload  Spatial placement of implants Biomechanical Overload See Figure 8-23 Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Baseline radiograph 4-year clinical photo 4-year radiograph Implants can fail for reasons other than poor homecare. Implant prosthesis was ill fitting and resulted in occlusal interference with protrusive movements. Suboptimal Positioning of Dental Implants Figure 8-26 Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Courtesy of Dr. Takahiro Fujii, Indianapolis, IN. Courtesy of Dr. Takahiro Fujii, Indianapolis, IN. Implants place to close together and too far facially. Clinical Signs of a Failing Implant  Soft tissue indicators:  Peri-implant pocket  Bleeding after gentle probing  Suppuration from pocket Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Implant mobility: Best indicator for implant failure! Radiographic Signs of a Failing Implant  Vertical destruction of crestal bone around implant while bottom portion remains osseointegrated  Wedge-shaped defects Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Bone loss adjacent to implant Radiographs of Progressive Peri-Implant Bone Loss Over a 3-Year Period Base line radiograph Radiograph at crown delivery Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com One-year post-op radiograph Three years post op radiograph Treatment Modalities for Failing Implants  Available methods:  Nonsurgical periodontal instrumentation  Use of antiseptics/ Chlorhexidine  Local and/or systemic antibiotics  Access flap surgery & bone grafting Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  No standard protocol at this time  Nonsurgical periodontal instrumentation with local delivery of minocycline or chlorhexidine may be helpful  Subgingival glycine air powder polishing to remove biofilm may reduce inflammation. Probing  Initial probing once final restoration is installed to assess the status of peri-implant tissues  Some surgeons recommend avoiding probing until healing is complete/ 3 months after abutment Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com connection.  Use light force because the peri mucosal seal is weakly adherent to the titanium surface Probing (cont.)  Plastic probes are often used  Metal probe okay if pressure is kept light Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Unlike natural teeth it is not possible to define the range of probing depths  Changes in probing depths over time are valuable Bleeding and Suppuration  Indicators of peri-implant tissue inflammation  Must eliminate with improved biofilm removal  Increasing probing depth and presence of bleeding or Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com suppuration warrant radiographic assessment.  If bleeding or suppuration are present, record them at specific sites  Figure 8-27 Radiographs  Take prior to cementation of implant crown to:  Ensure the absence of any pathology indicative Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com of infection  Verify spatial positioning of the implant  This radiograph shows radiolucency at the apex. Radiographs (cont.)  Take post-prosthetic insertion x-ray on day of cementing of implant crown to assess for Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com presence of remaining excess cement  Follow-up radiographically at least once a year Excess cement on the mesial surface of the crown. Radiographs (cont.)  Baseline radiographs:  On day of implant placement  On day of final prosthesis Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com insertion  Periodically during implant maintenance Goals of Maintenance Therapy for Dental Implants  Maintenance of alveolar bone support  Control of inflammation  Maintenance of healthy and functional implant Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Maintenance of healthy and functional periodontium surrounding neighboring teeth The Dental Implant Maintenance Visit  Modern implants often difficult to recognize intraorally  Must clearly note exact Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com location in chart  Update radiographs annually and review © Wolters Kluwer before instrumentation Instrumentation  Supragingival scaling with traditional instruments.  Subgingival scaling with like metals: Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Titanium: slender and can be sharpened Polymer: bulky and not suited for subgingival scaling The Dental Implant Maintenance Visit (cont.)  Individualize maintenance visit based on:  Previous examinations and history  Evaluation of peri-implant tissue health  Examination of prosthesis/abutment components Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Evaluation of implant stability  Occlusal examination  Assessment of patient’s self-care  Radiographic examination  Treatment Maintenance Frequency  3-month maintenance interval for the first year following the restoration of the implant  After the first year, every 3 to 6 months Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Indications for more frequent maintenance intervals:  Reduced bone support around implants  Inflammation  Host response  Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Guidelines for Professional Maintenance Special Considerations for Polishing  Implants, abutments, and components do not require routine polishing  Polishing improves titanium surfaces only if previously roughened or scratched Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Air abrasives preferred for rough implant surfaces  Air polishing with glycine powder safe and effective Patient Self-Care of Dental Implants  Important to preventing peri-implant disease  Develop individualized routine for each patient  Patients may have long history of dental neglect and/or Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com poor plaque biofilm control  Provide self-care education appropriate for implants and effective, simple-to-use home care devices Care of Fixed Prosthetic Restorations  Fixed prosthetic crown fits over abutment  Self-care challenges:  Patient may regard it as same as natural tooth  Must adapt floss along the margin of the crown to properly Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com direct it into the sulcus and around the abutment  See Figure 8-34  Restoration may resemble a fixed bridge or involve complex denture-like prostheses attached to multiple implants Techniques and Devices for the Care of Fixed Prosthetic Restorations  Standard multi-tufted, soft nylon bristle toothbrush  Powered toothbrush safe for titanium surfaces  Interdental brushes effective for biofilm removal and Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com cleaning peri-implant sulcus  Dental floss used gently subgingivally  Oral irrigators to remove plaque biofilm  Antimicrobial mouth rinse Care of a Removable Prosthesis  Similar to traditional denture, but is attached to abutments by O-rings, magnets, or clips Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Can also be designed as implant- and tissue- supported prosthesis or overdenture Courtesy of Rodger A. Lawton, DMD, FACP, Olympia, WA.  Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Figure 8-36: Tufted dental floss is useful in cleaning the implant abutments and underneath the connecting metal bar. Techniques and Tools  Remember most implant components titanium  Select for ease of use and demonstrate use Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Fewer devices best  For metal bar:  Use tufted dental floss or gauze square to clean  Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Figure 8-36: Tufted dental floss is useful in cleaning the implant abutments and underneath the connecting metal bar.